1578998696 NPI number — LAKESHORE SURGICAL PRACTICE, PC

Table of content: (NPI 1578998696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578998696 NPI number — LAKESHORE SURGICAL PRACTICE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESHORE SURGICAL PRACTICE, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578998696
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROCKPORT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14420-1913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-637-2930
Provider Business Mailing Address Fax Number:
585-507-4707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 ERIE CANAL DR
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14626-4604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-637-2930
Provider Business Practice Location Address Fax Number:
585-637-2930
Provider Enumeration Date:
09/09/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
585-637-2930

Provider Taxonomy Codes

  • Taxonomy code: 2086S0102X , with the licence number:  239232 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02752716 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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